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Trauma

Trauma

OPEN FRACTURE

An open fracture, also called a compound fracture, is a fracture resulting in the bone penetrating through the skin. Open fractures are usually the result of high-energy trauma. These injuries are considered contaminated, but if they are left without treatment for 6 to 8 hours, they are considered infected. Open fractures are considered a medical or surgical emergency, and patients should be admitted for antibiotics, closed reduction/open reduction internal fixation (ORIF), and/or debridement.

Classification (Gustilo and Anderson)

Type I

Fracture with an open wound less than 1 cm in length

Clean, with minimal soft tissue damage/necrosis

Fracture is usually simple (transverse or short oblique) with minimal or no comminution.

Adequate skin coverage maintained

If a bone graft is required for repair, may be done immediately

No neurovascular compromise

Type II

Fracture with open wound greater than 1 cm in length

Clean, with mild to moderate soft tissue necrosis

Fracture is usually simple (transverse or short oblique) with minimal or no comminution.

Adequate skin coverage

No major neurovascular compromise

If a bone graft is required for repair, best done at the time of delayed primary closure when there is no evidence of infection1

Antibiotics should be given less than 3 hours after injury and for 24 to 72 hours minimum. Most infecting bacteria are skin flora, and so a first-generation cephalosporin is a good choice (e.g., Cefazolin 1 to 2 g IV followed by 1 g IVPB q8h until cultures are available). Penicillin G 10 to 20 million units IV daily divided q6h should be used in farm accidents and other tetanus-prone environment. Clindamycin can be used if the patient is found allergic to penicillin. Vancomycin and/or aminoglycoside antibiotic-impregnated polymethylmethacrylate beads may also be beneficial.

Wound closure should be performed as soon as possible under minimal skin tension to prevent nosocomial infections.

STRESS FRACTURE

A stress fracture is a fracture that develops due to cyclical loading on a bone. These forces are seen in people with overuse and repetitive activities, such as runners and athletes. Ninety-five percent of stress fractures occur in the lower extremity, most notably the neck of the 2nd metatarsal. They may take 14 to 21 days to present radiographically after a bony callus has developed. If x-rays are inconclusive, a three-phase technetium bone scan may be positive as early as 2 to 8 days after onset of symptoms. MRI may show early signs within 1 to 2 weeks, and exposes patient to less radiation.

GREENSTICK FRACTURE

A greenstick fracture is an incomplete fracture in which the cortex on only one side of the bone is cracked. They are more commonly seen in children due to their soft bones.

TURF TOE

Turf toe is a traumatic soft tissue injury of the 1st MPJ caused by forced hyperextension of the joint. Turf toe is more common in sports played on synthetic surfaces, hence the name “turf toe.” Turf toe results in plantar capsular and ligamentous injury, causing dislocation of the joint.

Symptoms

Symptoms include a painful swollen MPJ with decreased ROM and a history of trauma.

JAHSS Classification

Type I

Dorsal dislocation of the proximal phalanx, in which the metatarsal head punctures through the plantar capsule

The intersesamoidal ligament remains intact, and there are no fractures.

The deformity is tight and difficult to close reduce, and may require ORIF.

Type IIA

Dorsal dislocation of the proximal phalanx, in which the metatarsal head punctures through the plantar capsule

The intersesamoidal ligament is ruptured, and the sesamoids no longer remain apposed to one another.

The deformity is loose and easier to close reduce.

Type IIB

Dorsal dislocation of the proximal phalanx, in which the metatarsal head punctures through the plantar capsule

The intersesamoidal ligament remains intact, and there is a transverse avulsion fracture of one of the sesamoids.

A fractured sesamoid must be distinguished from a bipartite sesamoid, which has an incidence of 20%. The easiest way to make the distinction is to compare current radiographs with previous films, if available. When earlier films are not available, comparing the contralateral foot can be useful. Fractured sesamoids may show irregular jagged edges of separation with interrupted peripheral cortices, longitudinal or oblique division lines, or a bone callus formation.

aIf both sesamoids are removed, consider performing an IPJ fusion and Jones tenosuspension to prevent hammering.

ANKLE SPRAINS

Ankle sprains occur when the ligaments of the ankle are stretched or torn. There are three main types of ankle sprains: inversion sprains, eversion sprains, and high ankle sprains. Eversion sprains are rare for two reasons: The fibula prevents the foot from everting and the deltoid ligament on the medial ankle is very strong. High ankle sprains are syndesmotic injuries.

Most ankle sprains are inversion sprains, in which the foot inverts and the lateral ligaments are damaged. The position of the foot at the time of an inversion sprain determines which ligaments are damaged. When the foot is plantarflexed at the time of injury, the anterior talofibular (ATF) ligament is damaged. This accounts for 95% of ankle sprains. When the foot is dorsiflexed at the time of injury, the calcaneofibular ligament is most likely damaged. Due to its proximity, rupture of the calcaneofibular ligament may also result in tearing of the peroneal tendon sheath.

Diagnosis

Arthrograms

Arthrograms are useful only in acute ruptures while the ligaments are still damaged; after 5 to 7 days, fibrosis may seal off injury and arthrograms will be of no use. Dye is injected into the ankle joint and should remain in the ankle joint on x-ray. Some individuals have a normal connection between the ankle joint and the peroneal tendon sheath, which should not be misdiagnosed as a rupture. The integrity of the articular cartilage should also be inspected with an arthrogram. The dark bands of the articular cartilage should be apparent with the radiopaque dye between them forming the “Oreo cookie sign.” If the articular cartilage is damaged, the dye will extend into the subchondral bone.

Radiographs

Anterior drawer view is useful in diagnosing ATF ligament ruptures. A positive test is a 6-mm or greater gap between the posterior lip of the tibia and the nearest part of the talar dome.

Stress inversion view is used to diagnose calcaneofibular ligament ruptures. A talar tilt of greater than 5° as compared with the contralateral side indicates a rupture.

Treatment

Nonsurgical treatment is aimed at decreasing inflammation and splinting/supporting the damaged tissues to prevent reinjury.

Surgical treatment involves procedures that reinforce and stabilize the damaged and elongated ligaments. This often involves tendon transfers.

Surgical Treatment for Eversion Sprains

Schoolfied Procedure

The deltoid ligament is detached from the tibia, the foot is maximally inverted, and the ligament is reattached superiorly to the detachment site. The deltoid ligament is effectively advanced.

DuVries Procedure

A large cruciate form incision is made in the deltoid ligament and then sutured back together. The theory behind the procedure is that the resultant scar tissue will effectively reinforce and stabilize the medial ankle.

Wittberger and Mallory Procedure

The tibialis posterior (TP) tendon is split longitudinally down to its insertion. Half the tendon is detached proximally and passed inferiorly to superiorly through a drill hole in the distal tibia and sutured back on itself with the foot forcibly inverted.

Surgical Treatment for Inversion Sprains

Brostrum Procedure

Consists of reconstruction of torn or elongated lateral ankle ligaments and retinaculum by imbrication (overlapping) and suturing in a “pants over vest” fashion

Other Surgical Treatment for Inversion Sprains

DISTAL TIBIOFIBULAR SYNDESMOTIC INJURY

A distal tibiofibular syndesmotic injury is also called a high ankle sprain and accounts for 10% of all ankle sprains. The mechanism of injury is eversion, dorsiflexion, and pronation, which forces the talus against the fibula widening the mortise. This results in damage to the ligaments holding the tibia and fibula together. The distal tibiofibular syndesmosis is a fibrous joint connecting the bones just above the ankle joint. The distal tibiofibular syndesmosis is composed of the following four ligaments, listed from anterior to posterior:

Anterior inferior tibiofibular ligament

Tibiofibular interosseous ligament

Inferior transverse tibiofibular ligament

Posterior inferior tibiofibular ligament (PITFL; strongest)

The talar dome is wider anteriorly than posteriorly, and the syndesmosis shows elasticity of 1 to 2 mm when the foot moves from plantarflexion to dorsiflexion. Extreme dorsiflexion can cause separation of the distal tibiofibular articulation and injure the ligamentous structures.

Diagnosis

Diagnosis, Clinical

Dorsiflexion may elicit pain as the wider anterior portion of the talus is rotated into the mortise and separates the bones. There may also be pain on direct palpation of the syndesmosis.

External Rotation Test

Also called Kleiger test. Pain is elicited with dorsiflexion and external rotation of the foot when the knee is flexed at 90° and the leg is stabilized. This is the most reliable test for diagnosing a syndesmotic injury.

Distal Compression Test

Medial lateral compression at the level of the malleoli elicits pain due to compression of the ligaments.

Squeeze Test

Also called the Hopkins test or proximal compression test. Medial lateral compression at the midcalf level elicits pain due to a slight distraction that results distally at the syndesmosis. There is also the “crossed-leg test,” which mimics the mechanism of the squeeze test. In this test, the patient crosses the bad leg over the good leg, and the pressure from the knee on the midcalf mimics the squeeze test.

Diagnosis, Radiographic

Tibiofibular Overlap

Evaluated on ankle A/P radiograph. Measure the tibiofibular overlap from the medial aspect of the fibula to the lateral border of the anterior tibial prominence 1 cm above the plafond. The amount of overlap should be greater than 10 mm. On the mortise view, tibiofibular overlap should be greater than 1 mm.

Tibiofibular Clear Space

Evaluated on either ankle A/P radiograph or mortise view. Take the width between the medial aspect of the fibula and lateral border of the posterior tibia, fibular notch (incisura fibularis) 1 cm proximal to the plafond. This distance should be less than 5 to 6 mm, a value greater than this indicative of syndesmotic injury.

Medial Clear Space

Evaluated on either the ankle mortise or ankle A/P radiograph. Medial clear space is the distance between the lateral border of the medial malleolus and the medial border of the talus. This measurement should be less than 4 mm and is usually equal to the distance between the tibial plafond and the talus (dorsal clear space). Widening of the medial joint space greater than 4 mm indicates deltoid ligament injury and lateral talar translation.

Diagnosis, Intraoperative

Cotton Test

Performed during an ankle scope. A bone hook is used to laterally distract the fibula. A 3 to 4 mm lateral shift of the fibula indicates a syndesmotic instability.

Treatment

Surgical treatment may include a 4.5-mm cortical transsyndesmotic screw through four cortices. Screws are removed at 3 to 4 months. Screws left in tend to fail due to the normal motion between the tib and fib. There is also elastic fixation where the transsyndesmotic screw is placed only through three cortices of the fibula and lateral tibia. The theory being that this will allow some toggle motion, preventing the screw from breaking. There is also the TightRope available from Arthrex.

The actual ligaments of the syndesmosis may require primary repair, and a plantaris graft can be utilized to reinforce the structures. Syndesmotic fusion and ankle fusion are also options for patients with continued pain and instability.

This is based on the location of the fibular fracture with respect to the syndesmosis.

Type A

Fracture below the level of the syndesmosis (infrasyndesmotic)

Type B

Fracture at the level of the syndesmosis (transsyndesmotic)

Type C

Fracture above the level of the syndesmosis (suprasyndesmotic)

EPIPHYSEAL PLATE FRACTURES

Classification (Salter-Harris)

Associated with 35% of all skeletal injuries in children

Type 1 (6%)

Transverse minor fracture through growth plate

No shortening

Type 2 (75%)

Through growth plate and traveling above into the metaphysis

Extra-articular

Minimal shortening, with no functional limitations after healing

Type 3 (8%)

Through the growth plate and traveling below into the epiphysis

Intra-articular

Tilleaux-Chaput type fracture that can cause shortening

Type 4 (10%)

Oblique fracture through the epiphysis and metaphysis/diaphysis

Intra-articular

Type 5 (1%)

Crush injury of the growth plate

Growth plate disturbance that can cause shortening and is associated with poor prognosis

CALCANEAL FRACTURES

Calcaneal fractures account for 1% to 2% of all fractures and typically occur as a result of axial loading such as a fall from a height or an MVA. The mechanism of injury is by way of the lateral process of the talus being driven down into the neutral triangle. Twenty percent of calcaneal fractures are associated with a spinal fracture between T12 and L2, L1 being the most common. Lumbar radiographs are, therefore, recommended in all fall/calcaneal injury patients presenting with back pain. Surgical repair should be performed within 5 hours of injury before acute swelling begins. If this window is missed, surgery should be delayed until swelling subsides, usually around 7 to 10 days, but before the 3-week mark when consolidation of the fracture begins. The goal of ORIF is to reestablish height and length to the calcaneus and realign the articular cartilage. These patients should be monitored for compartment syndrome.

Mondor sign is a clinical indicator for a calcaneal fracture. Patients present with ecchymosis extending from the malleoli to the sole of the foot.

Böhler angle is useful in evaluating calcaneal fractures. Normal values range between 20° and 40°; average is around 30° to 35°. Measurements less than 20° are seen in calcaneal fractures. Surgeons should strive to correct Böhler angle following ORIF for optimal outcome.

Gissane angle (critical angle) is useful in evaluating calcaneal fractures. Normal is 120° to 145°; a fractured calcaneus will cause this angle to increase. Surgeons should strive to correct Gissane angle following ORIF for optimal outcome.

Fracture Lines

The primary fracture line extends obliquely through the calcaneus from the posteromedial to the anterolateral. The anteromedial fragment consists of the anterior process, the sustentaculum tali, and a portion of the posterior facet. The posterolateral segment contains the tuberosity, the lateral wall, and variable portion of the posterior facet. The primary fracture line is a vertical fracture oriented from superior to inferior at the Gissane angle and is the result of the lateral process of the talus being driven down into the calcaneus. Secondary fracture lines are more varied and are determined by the direction of force.

Secondary fracture lines are determined by the direction of force. It can extend into the calcaneocuboid joint separating the anterior process into anteromedial and anterolateral fragments, or it can extend medially separating the sustentacular fragment from the anteromedial fragment.

Fragments

Constant fragment (a.k.a. superomedial fragment, sustentacular fragment). Because of its strong ligamentous and tendon support, this fragment remains constant as far as its location relative to the talus. This is the fragment to which all other fragments are fixated.

Anteromedial fragment

Anterolateral fragment

Lateral articular fragment is found with a joint depression type of injury where a fragment consisting of the lateral portion of the posterior facet develops. It is termed semilunar fragment, and with the tongue type, it is termed thalamic or comet fragment.

Lateral wall fragment develops as a result of a hydraulic tangential burst that occurs when the posterior facet is driven down into the body of the calcaneus.